[The persistence of the müllerian duct]

OBJECTIVE

To report two rare cases of persistent müllerian duct syndrome.

METHODS/RESULTS

Two patients with normal chromosome studies (46, XY) are presented. The radiological evaluation showed structures compatible with those of the müllerian duct. These structures were completely excised with excellent results. The histological findings confirmed the clinical diagnosis.

CONCLUSIONS

Persistent müllerian duct syndrome is a rare form of male pseudohermaphroditism that presents difficulties in making the differential diagnosis from other conditions with a different etiopathogenesis and that are not completely defined.

[Arterial priapism. Resolution following embolization with autologous thrombus]

OBJECTIVE

To report our experience with the management of arterial priapism by embolization.

METHODS

Two patients with arterial priapism secondary to perineal trauma are described. Diagnostic evaluation included intracorporal blood gas, echo Doppler and selective pudendal arteriographic assessment. Treatment was by selective autologous embolization.

RESULTS

Detumescence was achieved and control follow-up evaluation at 12 and 24 months demonstrated normal erectile function.

CONCLUSIONS

In our view, selective embolization is an effective treatment for arterial priapism arising from perineal trauma.

[Renal transplant in patient older than 65 years of age]

OBJECTIVE

To analyze the outcome of renal transplantation in patients more than 65 years old.

METHODS

From 1991 to 1997, 83 renal transplants were performed in patients aged over 60 years at our institution; 20 of these patients were more than 65 years old. The control group comprised graft recipients under than age from the 477 cases that had undergone transplantation during the period 1980-1996. Graft donor selection was done according to standard practice. The immunosuppression protocol changed over time; 5 patients received triple therapy and another 15 patients received quadruple sequential immunosuppression therapy.

RESULTS

The mean age of the recipients was 66.8 years (range 65-72); 9 patients required dialysis after renal transplantation. Patients aged over 65 years had a 94% survival at 6 months, 88% at 12 months, and 88% at 48 months, whereas the survival rates for the control group were 96%, 95% and 87% for the respective time periods. Graft survival was 95% at one month, 90% at 3 months and 74% at 48 months versus 93%, 87% and 78% for the control group.

CONCLUSION

Patients more than 65 years old with chronic renal failure and who are on dialysis can benefit from renal transplantation.

[En bloc renal transplant from infant donors to adults]

OBJECTIVE

To analyze the medium-term outcome of en bloc transplantation of pediatric kidneys into adult patients, including the incidence and type of surgical complications.

METHODS

From November 1991 to December 1997, we performed 37 en bloc transplantation of pediatric kidneys into adult patients. The kidneys were harvested from donors less that 3 years old and/or weighing 15 kg. The mean follow-up was 24 months. Grafting was achieved by end-to-side anastomosis of the donor cava to the receptor external iliac and the aortic patch to the external iliac artery.

RESULTS

Three grafts failed, probably due to hilar torsion; the remaining were initially functioning well. Seven transplant removal were performed; 6 were due to thrombosis. The actuarial graft survival was 89.1% at one month, 80.83% at 12 months and 80.83% at 24 months.

CONCLUSIONS

The medium-term results of en bloc transplantation of pediatric kidneys into adult patients were excellent and demonstrate the efficacy of this type of grafts. Arterial and venous thrombosis were the most important complications, quantitatively and qualitatively.

[Incidence of tumors in renal transplant patients. Is there a changing tumor pattern in these patients?]

OBJECTIVE

To analyze the incidence of tumors in renal graft recipients, the course, treatment and its effect on the graft and patient.

METHODS

We conducted a retrospective and prospective study on 477 renal transplants performed at our hospital from 1980 to 1996. The tumor type, course and possible tumor-related factors (immunosuppression, age, sex, graft rejection, virus) were analyzed.

RESULTS

57 tumors were found; 41 patients had at least one tumor. The most common were skin, renal and lung cancer. Age, sex and immunosuppression were found to be tumor-related factors in renal transplant recipients.

CONCLUSIONS

Patients undergoing renal transplantation are at a higher risk for developing a tumor, above all in the older male patients. A relationship was found for immunosuppression, the number of drugs received and the number of rejection episodes. Furthermore, the tumor pattern in these patients is different from the usual pattern.

[Neurobiology of ejaculation and orgasm disorders]

OBJECTIVE

To determine the neurologic alterations of patients with ejaculatory and orgasmic disorders.

METHODS

A study of the neuroandrologic profile was performed in eight patients; 6 presented an ejaculation, one premature ejaculation and one presented an orgasm. The neuroandrologic profile consisted in performing selective electromyography of the bulbocavernosus muscle, recording of the S2-S4 evoked potentials, evoked somatosensory potentials of the pudendal nerve, electromyography of the smooth cavernous muscle (SPACE), sympathetic skin response and cystometry.

RESULTS

The sympathetic lesion was more frequent in the cases with an ejaculation (four cases; 66%); a pudendal efferent lesion was demonstrated in one case (17%) and a suprasacral lesion in one case (16%). A pudendal afferent lesion was observed in the two cases with premature ejaculation (100%). Both cases with an orgasm had a pudendal afferent lesion (100%) and one of them also presented a sympathetic lesion (50%).

CONCLUSIONS

An ejaculation appears to be caused by sympathetic, motor pudendal or suprasacral lesion. An altered perception of genital sensations due to lesion of the afferent pudendal pathway appears to be present in premature ejaculation. An orgasm could be ascribed to an alteration of the pudendal sensibility or to the absence of ejaculation.

[Neurobiology of erectile dysfunction in multiple sclerosis]

OBJECTIVE

To analyze the neurological alterations responsible for impotence in multiple sclerosis.

METHODS

We conducted a pharmacologic erection test and a neuroandrologic profile study in 11 patients with multiple sclerosis and impotence. This study consisted in: bulbocavernosus EMG, S2-S4 evoked potentials, somatosensory potentials of pudendal nerve, electromyography of cavernous smooth muscle (SPACE), sympathetic skin response (SSR) and cystometry.

RESULTS

The most frequent neurological lesion was complete suprasacral (7 cases; 64%) and parasympathetic (7 cases; 64%) lesions. The parasympathetic lesions were of the upper motor neuron type in 6 of the 7 cases (86%). Peripheral autonomic [sympathetic in 2 cases (18%); parasympathetic in 1 case (9%)] and pudendal lesions (3 cases; 27%) were also observed.

CONCLUSIONS

The main cause of impotence in multiple sclerosis could be ascribed to a suprasacral lesion. Some cases also present peripheral autonomic lesions.

[Sarcomatoid renal carcinoma]

OBJECTIVE

To analyze the pathological and clinical features of a variant of renal carcinoma: sarcomatoid renal carcinoma.

METHODS

Of 316 patients diagnosed as having a renal tumor from 1975 to 1995, 11 (3.5%) with a pathological diagnosis of sarcomatoid renal carcinoma were analyzed. The clinical history, biological data and diagnostic imaging findings of these patients were reviewed. All patients had undergone surgical exploration.

RESULTS

All the tumors showed a double cellular population, with a fusiform component. Histological analysis showed a high grade and stage tumor. Ten patients died from the disease, the mean survival rate was 9 months (range 2-48) following diagnosis.

CONCLUSIONS

Sarcomatoid carcinoma of the kidney is uncommon and can be occasionally difficult to distinguish from sarcoma. It has a worse prognosis than other variants of renal carcinoma.

[Usefulness of electromyographic techniques of the bulbocavernosus muscle in the diagnosis of neurogenic impotence]

OBJECTIVE

To analyze the utility of electromyographic study of the bulbocavernosus muscle.

METHODS

126 impotent patients were evaluated by physical examination and neuroandrologic profile. The physical examination consisted in an exploration of the anal tone and the bulbocavernosus reflex. The neuroandrologic profile consisted in selective electromyography of the bulbocavernosus muscle, the determination of the S2-S4 evoked potentials, somatosensory potential of the pudenal nerve, electromyography of cavernous smooth muscle (SPACE) sympathetic skin response and cystometry.

RESULTS

The results of the bulbocavernosus electromyography and S2-S4 evoked potentials were different from the data obtained from the physical examination of the anal tone and the bulbocavernosus reflex. Selective bulbocavernosus electromyography showed a sensitivity of 57% and a specificity of 84%. The S2-S4 evoked potentials showed a sensitivity of 61% and a specificity of 100%. The diagnostic value of the S2-S4 evoked potentials increased at 39 msec cutoff (sensitivity = 66%; specificity = 95%). Exploration of the anal tone is very specific for neurologic lesion in impotence (93%), but has a low sensitivity (30%). The clinical bulbocavernosus reflex showed a good specificity (85%) and sensitivity (75%) in the diagnosis of pudendal efferent lesion, but is less useful in the diagnosis of neurogenic impotence.

CONCLUSIONS

The highest diagnostic value was obtained with the S2-S4 evoked potentials. Selective electromyography of the bulbocavernosus muscle showed a moderate diagnostic value. Physical examination of peripheral pudendal innervation does not appear to be useful for screening for neurologic lesion in impotence because of its low sensitivity, which may be due to existing incomplete nervous lesions.

[Neurobiology of postoperative impotence after rectal excision]

OBJECTIVE

The present study was conducted to determine the changes in the neuro-andrologic profile of patients with impotence following rectal ablative surgery.

METHODS/RESULTS

The study comprised 18 patients who had undergone rectal surgery: abdominoperineal resection of the rectum (AP) in 12 cases (67%), anterior resection of the rectum (AR) in 6 cases (33%). The pharmacologic erection test was negative in 60% of the patients (56% of the AP cases and 67% of the RA cases; differences not significant). Sympathetic lesion was demonstrated in 67% of the patients (50% of the AP cases and 100% of the AR cases; significant difference). Parasympathetic lesion was demonstrated in 38% of the patients (56% of the AP and in none of the RA cases; tendency towards statistical significance). Pudendal lesion was demonstrated in 83% of the patients, although no significant differences concerning pudendal involvement were observed between both types of surgery (92% of the AP group and 67% of the RA group). The frequency of the pudendal lesion was significantly greater than the parasympathetic lesion and the sympathetic lesion tended to be significantly greater than the parasympathetic lesion in patients undergoing ablative rectal surgery. No significant differences were observed between the pudendal and the sympathetic lesion in these patients. No relationship was observed between the type of neurologic lesion and the results of the pharmacologic erection test.

CONCLUSIONS

The type of neurological lesion appears to be related with the level of the rectal surgery. The sympathetic innervation would be more frequently compromised in anterior resection of the rectum. The parasympathetic innervation would be more frequently compromised in abdominoperineal resection. The pudendal innervation would be affected by both types of surgical techniques.

[Neuroandrologic considerations in impotent patients with Peyronie's disease]

OBJECTIVE

To asses the neuroandrologic profile of impotent patients with Peyronie's disease.

METHODS

We conducted a pharmacological erection test and a study of the neuroandrologic profile of 13 impotent patients with Peyronie's disease. Eight patients hhad associated conditions and no associated disease was demonstrated in the remaining 5 patients. The neuroandrologic profile was based on bulbocavernous EMG, S2-S4 evoked potentials, somatosensorial potentials of pudendal nerve, cavernous smooth muscle electromyography (SPACE), sympathetic skin response, and cystometrogram.

RESULTS

SPACE was altered in all the cases. In the patients with no associated disease, all other data of the neuroandrologic profile were normal. Patients with associated conditions demonstrated more alterations in all other data of the neuroandrologic profile and significant differences were observed in 7 cases. No differences in the type of alterations of SPACE were observed in 7 cases. No differences in the type of alterations of SPACE were observed between both groups.

CONCLUSION

The impotence associated with Peyronie's disease could be due to an intrinsic lesion of the erectile smooth muscle.

[Evaluation of electromyography of the corpora cavernosa (single potential analysis of cavernous electric activity--SPACE) as a technique for studying impotence]

OBJECTIVE

To analyze the utility of data obtained by single potential analysis of cavernous electric activity (SPACE) in the study of impotence.

METHODS

127 patients with impotence were evaluated by neuroandrologic profile, SPACE, erection test post intracavernous injection of papaverine-phentolamine and a cystometrogram (CMG).

RESULTS

The quantitative characteristics (duration, amplitude, number of phases) of the SPACE potentials were not useful in distinguishing between the different types of impotence. The qualitative characteristics (degree of activity, morphology, synchrony and coordination) during erection were significantly different between the non-neurogenic and neurogenic impotence. Significant differences were found in the qualitative characteristics (synchrony and coordination during erection) between patients with no demonstration of organic impotence and those with a negative erection test and no alterations in the neuroandrologic profile (vascular impotence). No relationship was found between the degree of activity of the SPACE and the presence or absence of voiding reflex in the CMG.

CONCLUSION

SPACE is a useful technique in the study of impotence, although the interpretation of the data are more qualitative than quantitative. The CMG provides complementary data and should therefore continue to be included in the study of the neuroandrologic profile in impotence.

[Analysis of pudendal nerve somatosensory evoked potentials in the diagnosis of neurogenic impotence]

OBJECTIVE

To determine the utility of the somatosensorial evoked potentials of the pudental nerve in the diagnosis of neurogenic impotence.

METHODS

129 patients with impotence were evaluated by physical examination and neuroandrologic profile. The neuroandrologic profile was assessed by bulbocavernous electromyography, determination of S2-S4 evoked potentials, analysis of the somatosensorial potentials of the pudendal nerve, cavernous smooth muscle electromyography (SPACE), sympathetic skin response and cystometry.

RESULTS

The patients with a neurologic lesion presented a significantly longer latency time of the somatosensorial potentials than those with no neurologic lesion. The sensitivity of the somatosensorial potentials was 63% and the specificity was 98%. The sensitivity could be enhanced without significantly lowering specificity by taking 49 msec as the upper limit of normal values in latency time. The determination of the voluntary anal control in the diagnosis of neurogenic impotence was found to have a high specificity (93%), but a low sensitivity (42%).

CONCLUSION

The determination of the somatosensorial potentials, unlike other techniques, could allow diagnosis of lesions of the suprasacral inneveration in the evaluation of neurogenic impotence. The evoked somatosensorial potentials of the pudendal nerve and physical examination have the inconvenience of their low sensitivity in regard to the diagnosis of neurogenic lesion in impotence, mainly because some conditions only affect the peripheral autonomic innervation and the somatic element is spared.

[Current status of the study of genital sympathetic evoked potentials in the assessment of impotence]

OBJECTIVE

To determine the usefulness of penile sympathetic skin response (PSSR) in the study of impotence.

METHODS

The PSSR, hand sympathetic skin response (HSSR), filling videocystography and SPACE (single potential analysis cavernous electromyography) were performed in 39 patients referred for study of impotence.

RESULTS

A relationship between not obtaining PSSR and an open bladder neck (60%) in the videocystography at filling, and between a closed bladder neck and obtained PSSR (81%) was demonstrated. The percentage of normal hand sympathetic potentials was similar for patients with obtained and not obtained PSSR. The relationship between the degree of activity of the SPACE and the type of PSSR could not be demonstrated.

CONCLUSION

The determination of the PSSR allows us to evaluate the sympathetic cavernous innervation. This would obviate performing a filling videocystography in the study of the neuroandrologic profile in impotence. The information obtained by PSSR is independent of that obtained from SPACE, therefore both procedures complement each other in the neuroandrologic study of impotence.

[Assessment of sensory thresholds of the penile dorsal nerve as screening technique for neurologic lesion in impotence]

OBJECTIVE

The present study was conducted to determine the usefulness of the perception and stimulation thresholds of the penile dorsal nerve in the diagnosis of neurogenic impotence.

METHODS

A study was conducted to determine the neuroandrologic profile in 130 patients. According to the results of the neuroandrologic profile, they were classified as patients without neurogenic impotence (44 pts.; 34%) or with neurogenic impotence (86 pts.; 66%). The perception and stimulation thresholds (expressed in milliAmperes) were determined in all patients. Furthermore, the perineal sensation was clinically tested. Both thresholds were also studied in relation to a demonstrated neurologic lesion (sympathetic, parasympathetic, afferent pudendal, efferent pudendal and suprasacral lesions).

RESULTS

Assessment of the perineal sensation demonstrated a high specificity and a low sensitivity in the diagnosis of neurogenic impotence. A significant difference was observed between both groups for the perception (confidence interval of difference between the neurogenic and non-neurogenic group; from 0.02 to 4.95 mA) and stimulation thresholds (from 2.0 to 11 mA). Morever, the stimulation threshold was significantly higher in patients with alteration of the perineal sensation). Significant differences in the perception threshold were also demonstrated between patients with and without demonstration of efferent lesion, and in the stimulation threshold between patients with and without demonstration of pudendal afferent, pudendal efferent and sympathetic lesion. These differences are attributed to the presence of mixed lesions. However, given the width of the interval of normal values, it was not possible to find a useful cut-off point in both sensory thresholds. It could only be determined that the maximum value of the perception threshold in healthy subjects should be less than 9.45 mA.

CONCLUSION

The sensorial thresholds of the electrical stimulation of the penile dorsal nerve and the data from the physical examination of perineal sensation are not useful for the diagnosis of neurogenic impotence. It is necessary to carry out a complete neuroandrologic profile.

[Usefulness of the neuroandrologic profile study in patients with erectile dysfunction: review of a series of 180 cases]

OBJECTIVES

To determine the usefulness of a complete neuroandrologic evaluation and SPACE (Single Potential Analysis Cavernous Electromyography) in the study of impotence.

METHODS

We performed a clinical study, erection test with papaverine-phentolamine and neuroandrologic evaluation (bulbocavernous EMG, S2-S4 evoked potentials, evoked somatosensorial potentials, SPACE, D10-L2 skin sympathetic potentials, cystometrogram, and filling videocystography) in 180 patients consulting for impotence.

RESULTS

We observed a relationship between the clinical diagnosis of impotence and the data from the neuroandrogenic study. The results of the study were classified as normal [in the clinical diagnosis of psychogenic impotence (100%), hormonal (80%) and vascular (60%)], abnormal [prevalent in the clinical diagnosis of structural impotence (87%)]. The erection test was mainly negative in all clinical diagnoses of impotence, except in psychogenic and vascular impotence (60% positive tests).

CONCLUSIONS

The clinical data are useful in the diagnosis of impotence. The pharmacological erection test was not found to be very reliable. Complete neuroandrologic evaluation is indicated in non typified and mixed impotence, and can be performed in neurogenic impotence to identify the level of the lesion. Alone, SPACE does not appear to be useful as a screening test for neurologic lesions, but can be useful as a screening test for neuromuscular cavernous lesions. SPACE is indicated in structural, vascular and hormonal impotence. If SPACE is abnormal, the differential diagnosis between neurogenic and myogenic lesion can be made through a complete neuroandrologic evaluation.

[Basic concepts in the use of tumor markers in the diagnosis and follow-up of malignant bladder neoplasms]

The absence of reliable diagnostic elements for the evaluation of malignant bladder tumors and the low sensitivity of the conventional diagnostic methods have prompted studies on the biological behaviour of this tumor type. The well known studies of Gold and Freedman and the recent investigations of Bates and Logo have proposed using tumor markers for early diagnosis and follow-up of different types of malignant tumors. However, the "ideal" tumor marker, one that is sufficiently sensitive and specific, has as yet to be discovered. We reviewed the tumor markers widely utilized to diagnose and follow-up malignant bladder tumors, and describe their main features. It must be pointed out that the lack of sensitivity and specificity of these tumor markers have led to the development of a new generation of tumor markers, such as cytogenetic markers, oncogenes, etc. Undoubtedly, this review of the literature will become obsolete with the advent of subsequent generations of tumor markers.

[Conservative treatment of ureteral iatrogenesis of gynecologic origin]

Five patients with iatrogenic ureteral injuries are described herein. Two patients had a vesicoureteric fistula and the remaining three patients had obstructive uropathy secondary to ligation with resorbable material during hysterectomy for a benign uterine condition, which spontaneously resolved with conservative management. Classically, the approach of this type of lesion was interventional and careful patient selection afforded the possibility of definitive resolution. US, CT and modern endourological technology have facilitated temporary diversion via percutaneous nephrostomy (or surgery, if the foregoing is not possible) to protect renal function during the process of recanalization of the injured ureter. Furthermore, it permits radiological control of the course and functional assessment of the excretory tract.

[Retroperitoneal abscess: analysis of 26 cases]

Herein we present the experience of our hospital, which spans a period of 10 years, in the diagnosis and treatment of retroperitoneal abscess. The clinical features, origin and localization of the abscesses are described. We underscore the diagnostic value of ultrasound (US) and computerized tomography (CT) which afford a sensitivity of 86.3% and 100%, respectively. An increased incidence of abscess from gram-positive bacteria was observed in i.v. drug addicts.

[Renal injury on a pathological kidney. Incidence, management, and results of treatment]

The present study reports our experience in the management of 13 patients with trauma to previously asymptomatic pathological kidney (11.6% of 112 cases of renal trauma treated over the period 1980-1990). The diagnostic difficulties and treatments, which are unlike those of trauma to normal kidney, are discussed and the literature reviewed. Hydronephrosis from ureteropelvic junction stenosis was the preexisting pathology that was frequently diagnosed (41.6%), followed by trauma to kidney with tumor (30.7%). Twelve (92%) patients underwent surgery: 2 (15.3%) were emergency and the rest were elective surgery. One patient with hilar sinus cysts received medical treatment. Conservative surgery was performed in 5 renal units (1 with bilateral involvement) and nephrectomy was performed in 8 patients (65.1%). The kidney with a tumor is more compromised by the renal injury. Furthermore, post trauma contusion/laceration of the tumor may present problems relative to tumor stage.

[Penile metastases. Report of 3 new cases and review of the national literature]

Penile metastasis from primary tumors at other sites are extremely rare. To our knowledge, Alonso Gorrea reported the first case in the Spanish literature in 1980. Since then, 20 cases have been reported. Three additional cases of penile metastasis from tumors at other sites are described herein. The pathogenesis, symptoms, prognosis and treatment of this tumor type are discussed.

[Leiomyoma of the lower urinary tract]

Tumors of mesothelial origin account for 1-5% of all vesical neoplasms. Leiomyomas, although rare, are the most frequently encountered. Three patients diagnosed as having leiomyoma are presented. Two had leiomyoma of the bladder and one had leiomyoma of the distal urethra. The etiopathogenesis, diagnosis and treatment of this tumor type are discussed.

[Spontaneous subcapsular and perirenal hematoma in a patient undergoing periodic hemodialysis]

Spontaneous renal subcapsular hematoma in patients undergoing hemodialysis is a very uncommon condition that is attributed to acquired cystic disease of the kidneys and other causes. We report on a patient undergoing hemodialysis due to chronic renal failure who developed right spontaneous perirenal subcapsular hematoma ascribable to no underlying pathology. Treatment was by nephrectomy.

[Priapism secondary to phenothiazines]

We report two cases of priapism in patients previously treated with neuroleptic agents. None of these patients had a previous history of urological or hematological disorders. These two patients warranted emergency treatment by punction-aspiration of the corpora cavernosa and posterior cavernospongiosa shunt. The foregoing approach achieved penile detumescence in both cases. Excellent results were achieved relative to erectile function in one patient. Although the mechanism responsible for phenothiazine-induce priapism has as yet not been elucidated, it has been suggested that this might be due to adrenergic block which directly inhibits the sympathetic impulse of detumescence.

[Benign hypertrophy of the prostate: pathogenic aspects]

In 106 male human cadavers the incidence of benign prostatic hyperplasia was found to be 63%. The present review confirmed age to be a determinant factor of the first order in the development of adenoma of the prostate. A delay in the presentation of BPH was observed in the cirrhotic alcoholic. Surprisingly, prostatic hyperplasia was not observed in those who had died from genitourinary, gastric or malignant hematologic diseases. No evidence of BPH was observed in 68.4% of patients who had died of cancer.

[Clinical and urodynamic results of the treatment of bladder instability with intravaginal/intrarectal electric stimulation]

Twenty-six male and female patients with urinary incontinence due to vesical instability underwent intravaginal/intra-rectal electrostimulation therapy. Positive clinical results were achieved in 65.3% of the cases. During subsequent urodynamic study, 80% of these cases showed absence of vesical instability. Based on these results, intravaginal/intra-rectal electrostimulation would constitute an option for the treatment of urinary incontinence due to vesical instability.

[Bladder endometriosis: review and presentation of 2 new cases]

Two cases of vesical endometritis in two women aged 48 and a 46 years respectively are presented. Both cases were detected incidentally during a gynecological and vesical ultrasound study and the diagnosis was confirmed by cystoscopy and transurethral resection and histopathological exam. An exhaustive literature review is also presented and we insist on the rare presentation and the relatively specific clinical symptoms. A special note is made on the cystoscopic findings and on the different treatment techniques, including the latest approach with LH-RH analogues and/or transurethral photocoagulation with laser rays.